Adult Critical Care Specialty (ACCS) Practice Exam

Which therapy is recommended for a patient with a depressed skull fracture to maintain low ICP?

1. Position the head of the bed at 30 degrees or greater

2. Administer mannitol

3. Maintain PaCO2 at 25-30 torr

4. Control fever and agitation

The correct answer is: Position the head of the bed at 30 degrees or greater

The best choice for maintaining low intracranial pressure (ICP) in a patient with a depressed skull fracture involves positioning the patient appropriately. Elevating the head of the bed to 30 degrees or greater facilitates venous drainage from the cerebrospinal fluid (CSF) and reduces the overall pressure within the cranial cavity. This position helps to improve cerebral perfusion and can effectively decrease ICP by allowing for more efficient venous return, thereby optimizing the dynamics of intracranial compliance. While administering mannitol can also help reduce ICP through an osmotic diuretic effect, the primary goal in the case of a fractured skull is to manage ICP through less invasive means such as body positioning before initiating pharmacological interventions. Maintaining a low PaCO2 level can theoretically decrease ICP by inducing vasoconstriction, but it's important to balance ventilation strategies carefully, especially in patients with head injuries. Fever control and managing agitation are also important for overall care, but they are more related to general management rather than specifically addressing ICP reduction. Therefore, positioning the patient with the head of the bed elevated is a straightforward and effective initial strategy to mitigate increased intracranial pressure in the context of a depressed skull fracture.